AHRQ Innovations Exchange | Post-Discharge Telephone Followup With Chronic Disease Patients Reduces Hospitalizations, Emergency Department Visits, and Costs

Post-Discharge Telephone Followup With Chronic Disease Patients Reduces Hospitalizations, Emergency Department Visits, and Costs

Snapshot
Summary
Kaiser Permanente Colorado Region’s chronic care coordination program employs coordinators to provide telephone-based support to patients recently discharged from the hospital or a skilled nursing facility and to other high-risk enrollees. Coordinators identify care needs, help individuals develop self-management skills, and ensure access to needed clinical and social services. The program has led to significant reductions in hospitalizations and emergency department visits, resulting in an estimated $4 million in savings to Kaiser Colorado. The program has also encouraged more patients to complete their followup care, improved medication compliance, and yielded high levels of provider and patient/family satisfaction.

See the Description section for new information about program eligibility and assessment and the Results section for updated information on inpatient re-admissions and medication compliance (updated November 2009).

Evidence Rating
Moderate: The evidence consists of comparisons of key metrics (readmission rates and ED visits) between enrollees receiving program services and similar enrollees receiving usual care, physician and patient survey data, and cost savings.

Developing Organizations
Kaiser Permanente Colorado


Date First Implemented
2003

Patient Population
Geographic Location > State; Vulnerable Populations > Frail elderly; Medically or socially complex


What They Did
Problem Addressed
Patients who are recently discharged from a hospital or skilled nursing facility often suffer complications that lead to the need for readmission. Many of these complications result from the failure to understand and appropriately manage post-discharge care needs, such as self-management requirements and medication regimens, or a lack of access to needed medical and social services.

Poor transitional care: Patients undergoing transitions after discharge often face deficiencies in the quality of their care, including insufficient education about self-management of their condition, conflicting advice regarding care, and a lack of an identified provider who can monitor them during and after the transition.1
Poorer outcomes, higher costs: Deficiencies in transitional care lead to higher costs, medical errors, and poor compliance with medication regimens.2,3

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AHRQ Innovations Exchange | Post-Discharge Telephone Followup With Chronic Disease Patients Reduces Hospitalizations, Emergency Department Visits, and Costs